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ORIGINAL ARTICLE

Outcomes and stability in patients with anterior


open bite and long anterior face height treated
with temporary anchorage devices and a maxillary
intrusion splint
Nicole R. Schefer,a William R. Proft,b and Ceib Phillipsc
Chapel Hill, NC

Introduction: Temporary skeletal anchorage devices now offer the possibility of closing anterior open bites and
decreasing anterior face height by intruding maxillary posterior teeth, but data for treatment outcomes are lacking. This article presents outcomes and posttreatment changes for consecutive patients treated with a standardized technique. Methods: The sample included 33 consecutive patients who had intrusion of maxillary posterior
teeth with a maxillary occlusal splint and nickel-titanium coil springs to temporary anchorage devices in the
zygomatic buttress area, buccal and apical to the maxillary molars. Of this group, 30 had adequate
cephalograms available for the period of treatment, 27 had cephalograms including 1-year posttreatment, and
25 had cephalograms from 2 years or longer. Results: During splint therapy, the mean molar intrusion was
2.3 mm. The mean decrease in anterior face height was 1.6 mm, less than expected because of a 0.6-mm
mean eruption of the mandibular molars. During the postintrusion orthodontics, the mean change in maxillary
molar position was a 0.2-mm extrusion, and there was a mean 0.5-mm increase in face height. Positive
overbite was maintained in all patients, with a slight elongation (\2 mm) of the incisors contributing to this.
During the 1 year of posttreatment retention, the mean changes were a further eruption of 0.5 mm of the
maxillary molars, whereas the mandibular molars intruded by 0.6 mm, and there was a small decrease in
anterior face height. Changes beyond 1 year posttreatment were small and attributable to growth rather than
relapse in tooth positions. Conclusions: Intrusion of the maxillary posterior teeth can give satisfactory correction
of moderately severe anterior open bites, but 0.5 to 1.5 mm of reeruption of these teeth is likely to occur. Controlling the vertical position of the mandibular molars so that they do not erupt as the maxillary teeth are intruded
is important in obtaining a decrease in face height. (Am J Orthod Dentofacial Orthop 2014;146:594-602)

keletal open bite, often called the long-face syndrome or condition, is regarded as a challenging
orthodontic problem to correct. Many orthodontic
treatment modalities have been used to close anterior
open bites, such as extractions, multiloop edgewise archwires, high-pull headgear, chincups, bite-blocks, and
From the Department of Orthodontics, School of Dentistry, University of North
Carolina, Chapel Hill, NC.
a
Adjunct associate professor.
b
Kenan distinguished professor.
c
Professor and associate dean.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported.
Supported in part by NIH grant DE-02115 from the National Institute of Dental
and Craniofacial Research.
Address correspondence to: Nicole R. Schefer, 373 Boone Heights Dr, Boone,
NC 28607-5022; e-mail, smileboone@gmail.com.
Submitted, April 2014; revised and accepted, July 2014.
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.07.020

594

functional appliances,1-6 but relapse is common, and


even the combination of headgear and a functional
appliance is ineffective in changing the skeletal
pattern.7 Orthognathic surgery to reposition the maxilla
superiorly has been the only way to create signicant
rotation of the mandible upward and forward, decreasing
anterior face height along with correction of the open
bite. Recently, temporary anchorage devices (TADs),
including miniplates and miniscrews, have been used to
intrude the maxillary posterior teeth to allow autorotation of the mandible to close an anterior open bite.8-12
There have been only a few reports of outcomes with
this approach beyond individual case reports. Kuroda
et al13 concluded in an early article on this method that
molar intrusion with TADs is as successful as surgery,
but this was based on a small sample of 10 subjects. In a
case series of 9 patients treated with maxillary posterior
intrusion who had open bites that remained closed, Sugawara et al14 reported a 27% to 30% relapse of the maxillary

Schefer, Proft, and Phillips

molars within 1 year. Baek et al15 reported a maxillary


molar relapse of 23% and an overbite relapse of 17%
over 3 years in a case series of 9 anterior open-bite patients. Deguchi et al16 reported a 22% maxillary molar
relapse and an overbite relapse of 13% over 2 years in a
study comparing 15 patients treated with TADs and premolar extractions with 15 patients treated with conventional edgewise treatment and premolar extractions. In a
report using an earlier intrusion sample from the University of North Carolina with a mixture of lingual arch and
splint stabilization during intrusion, Prott et al17 noted
that clinically signicant reeruption of intruded maxillary
molars occurred in about half the patients by 1 year postsurgery. There have been no other previous reports of stability longer than 1 year that included more than 10
consecutively treated patients with the same treatment
protocol.
The purposes of this study were to (1) document in a
series of consecutively treated patients the amounts of
molar intrusion, open-bite correction, and decrease in
anterior face height obtained with TADs (miniplates or
miniscrews) at the base of the zygomatic buttress and
delivery of the intrusion force to a splint covering the
maxillary posterior teeth; and (2) evaluate the stability
of the intrusion from the completion of active intrusion
to the end of orthodontic treatment, at 1 year posttreatment, and at 2 years or longer posttreatment.
MATERIAL AND METHODS

The initial sample consisted of 33 consecutive patients with open bite and long face treated by intrusion
of the maxillary posterior teeth in the private orthodontic
practice of the senior author (N.R.S.) in Boone, NC, from
September 21, 2005, to September 26, 2012. The routine
clinical protocol included lateral cephalometric radiographs at the beginning of intrusion (T1), at its completion when the maxillary splint was removed (T2), at the
completion of orthodontic treatment (T3), at the 1-year
recall (T4), and at 2 or more years posttreatment (T5).
All open-bite patients who accepted treatment with
this protocol (TADs and intrusive force to an occlusal
splint) were included in the initial sample. This was a
retrospective observation study, not a randomized clinical trial; the consecutive-patients approach was to verify
that these patients were not selected on the basis of their
treatment outcome. Three of the initial 33 patients were
dropped because an adequate cephalogram was not obtained at T2 or T3. The nal sample consisted of 11 male
and 19 female subjects. Three of them did not return for a
1-year cephalogram, so 1-year data were available for 27
patients. Twenty-ve of these patients returned for a
cephalogram at 2 or more years posttreatment. Their

595

Table I. Characteristics of the sample


N (%) Mean SD
Range
Female
19 (63)
Male
11 (37)
Growing patients (\age 20)
15 (50)
Age at start of treatment (y)
30
24.1 10.7 12.7-48.1
Initial overbite (mm)
30
1.2 1.7 5.0 to 1.8
Time in splint treatment (y)
30
0.5 0.1 0.3-0.8
Total time in treatment (y)
30
1.6 0.6 0.5-2.8
Debond to 1-y ceph (T3-T4) (y)
27
1.0 0.1 0.7-1.3
Debond to .2-y ceph (T3-T5) (y) 25
2.5 0.7 1.5-4.8
Ceph, Cephalogram.

sex distribution, initial open-bite severity, age, and treatment timing characteristics are shown in Table I.
The clinical technique used with these patients is
described in some detail in a recent publication,18 and
the treatment steps are shown in Figure 1. In brief summary, all patients had a maxillary intrusion splint (AOB-I
buccal splint; AOA Laboratories, Sturtevant, Wis) that
was bonded to the maxillary teeth, TADs (miniscrews
or miniplates) bilaterally at the base of the zygomatic
arch, and nickel-titanium coil springs to deliver the
intrusive force to the splint (Fig 1, B). Nickel-titanium
coil springs with similar forces were used with both miniplates and miniscrews. After the completion of intrusion
and removal of the splint, a continuous edgewise wire
was placed in all maxillary brackets, and the molars
were ligature-tied to the TADs (Fig 1, C). After completion of orthodontic treatment (Fig 1, D), a suck-down
retainer with buttons bonded lingual to the maxillary
molars was provided the same day and worn nightly
with elastics to the buccal TADs (Fig 1, E). Three weeks
later, an occlusal coverage AOB hooked retainer (AOA
Laboratories) (Fig 1, F) was provided, with elastics
worn nightly to the buccal TADs for the rst 6 months.
Then the retainer was worn without elastics indenitely.
For 16 patients, Vector TAS miniscrews (length, 8 mm;
diameter, 1.4 mm; Ormco, Orange, Calif) were placed by
the orthodontist (N.R.S.) on the buccal side between
either the second premolar and the rst molar or the rst
and second molars, and they were loaded immediately.
The other 14 patients had miniplates placed by the
same surgeon. The choice of miniplates vs miniscrews
was based on whether the patient also had a Class II or
Class III malocclusion in conjunction with the anterior
open bite. Miniplates with screws placed above the maxillary roots were chosen if translation of molars was necessary to correct the malocclusion. Of the 14 patients with
miniplates, 12 had Leibinger Skeletal Anchoring miniplates (Stryker, Kalamazoo, Mich) retained by 3 screws
and 2 had C-Tube OrthoAnchor miniplates (KLS Martin,
Jacksonville, Fla) retained by 2 screws. The miniplates

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596

Fig 1. A, A 40-year-old man with an anterior open bite with occlusion only on rst and second molars;
B, intrusion with an AOB-I buccal splint with 2 nickel-titanium coil springs (150 g) attached to the second
and fourth hooks of the AOB-I and buccal TADs bilaterally; C, occlusal relationship after intrusion with
the AOB splint with molars ligature-tied to the TAD; D, nal occlusal relationship at deband (treatment
time was 20 months); E, immediate retention with lingual xed retainers and a suck-down retainer with
buttons bonded lingual to the maxillary molars worn nightly with elastics to the buccal TADs for 3 weeks;
F, after 3 weeks, an AOB hooked retainer was provided and worn nightly for 6 months with elastics to
the bilateral TADs and then continued without elastics indenitely with the TADs removed; G, after
2 years of retention, the anterior open bite remained closed.

were loaded 18.7 6 13.9 days later (range, 7-56 days).


Intrusion was continued until a positive overbite was obtained. There were no failures of miniplate anchorage; in
1 patient, a miniscrew that was becoming loose was
immediately replaced so that there was no interruption
in the intrusion force during active intrusion treatment.
In another patient, one miniscrew fell out the day after
the patient was debanded and was not replaced, and
the other miniscrew was not used during retention.
Statistical analysis

All cephalograms were digitized by a skilled technician at the University of North Carolina. Seven measurements were made at each of 5 time points to evaluate the
skeletal and dental changes from intrusion and the
amount of change after intrusion.

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In this study, the outcomes of interest were the 7


cephalometric variables shown in Table II. Each
outcome was analyzed separately by a marginal multivariate regression model with covariates (visit, age at
initial visit categorized as younger vs older than 20,
sex, and the pairwise interactions of age by visit and
sex by visit). The interactions were included to assess
whether the pattern of change for age and sex was
similar over time. Considering the repeated measure
property of the outcomes, the general estimating equation method with an autoregressive working correlation
matrix was used. Interactions were removed if they were
not statistically signicant, and a reduced model was
run. Signicant interactions were assessed using graphic
plots. The level of signicance was set at 0.05 for all analyses.

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597

Table II. Changes in cephalometric variables


Initial to splint out
(n 5 30)
Variable
LAFH (ANS-Me) (mm)
GoGn-SN ( )
Overbite (mm)
U1-PP (mm)
U6-PP (mm)
L6-GoGn (mm)
L1-GoGn (mm)

Mean
1.6
1.2
2.2
0.3
2.3
0.6
0.6

SD
2.2
1.0
1.6
1.8
1.4
1.6
1.0

Splint out to debond (n 5 30)


Mean
0.5
0.2
0.9
0.7
0.2
0.7
0.8

SD
2.1
1.1
1.3
1.9
1.1
0.8
1.2

Debond to 1 year (n 5 27)


Mean
0.2
0.0
0.3
0.3
0.5
0.6
0.2

SD
1.4
0.9
0.8
1.0
1.1
1.3
0.9

Debond to .2 years
(n 5 25)
Mean
0.3
0.0
0.4
0.3
0.5
0.3
0.1

SD
1.4
0.8
1.1
1.2
1.2
1.3
1.2

RESULTS

The analysis showed that the pattern of response over


time for the younger and older subjects was statistically
signicantly different for mandibular incisor to mandibular plane (P 5 0.0002), mandibular molar to mandibular
plane (P 5 0.02), mandibular plane angle (P 5 0.01), and
anterior face height (P 5 0.03). In all instances, there
were greater changes in the younger group. The pattern
of response over time was also statistically signicantly
different for the sexes, with greater changes in the male
patients for mandibular incisor to mandibular plane,
mandibular molar to mandibular plane, and maxillary
molar to palatal plane (P \0.0001 for all 3). Change in
overbite was not linked to age or sex.
The means and standard deviations for changes between T1 and T2 for selected cephalometric variables
are shown in Table II. The mean change in the vertical
position of the maxillary molar during active intrusion
was 2.3 mm, which in turn decreased the mean anterior
face height and the mandibular plane angle by 1.6 mm
and 1.2 , respectively. The mean change for the mandibular molar was 0.6 mm of extrusion, and the mean
change in overbite was an increase of 2.2 mm.
The response in a group of patients to what seemed
to be identical treatment often is understood better by
looking at the percentage of the patient population
who had clinically signicant (.2 mm) or highly clinically signicant (.4 mm) changes. During active intrusion (T1-T2), 18 of the 30 patients (60%) had 2 to 4 mm
of intrusion of the maxillary rst molars, and 1 patient
(3%) had greater than 4 mm of intrusion (Fig 2). Two patients (7%) had greater than 4 mm of extrusion of the
mandibular molars, and 1 patient had 2 to 4 mm of
extrusion (ie, the mandibular molars erupted that
much while the maxillary molars were being intruded)
(Fig 3). Twelve patients (40%) experienced 2 to 4 mm
of decrease in anterior face height, and 3 (10%) had a
decrease greater than 4 mm (Fig 4). The percentage
with change in overbite was similar to that for anterior

Fig 2. Percent with change in the maxillary rst molar


distance from the palatal plane. Note that 60% of the patients had the molar intruded 2 to 4 mm during the splint
therapy for intrusion (T1-T2), but only 1 patient had
greater than 4 mm of intrusion. During the postintrusion
orthodontic treatment, only 2 patients (7%) had 2 to
4 mm of reeruption of the maxillary molars; during the
rst posttreatment year (T3-T4), 3 patients (11%) had
2 to 4 mm of downward movement, most likely caused
by continued vertical growth. From the end of treatment
to the more than 2-year recall, 4 patients (16%) had 2 to
4 mm of downward movement, which was also largely
due to vertical growth.

face height: 12 patients had 2 to 4 mm of increase in


overbite, and 5 had a greater than 4-mm increase.
There were changes during the postintrusion orthodontic treatment (T2-T3). After removal of the AOB
splint, the maxillary molars were ligature-tied to the

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Fig 3. Percent with change in the mandibular rst molar


distance from the mandibular plane. During splint therapy (T1-T2), 2 patients had greater than 4 mm of eruption of the mandibular rst molars (7%), and 1 (3%) had
2 to 4 mm of eruption. During postintrusion orthodontics
(T2-T3), 5 (17%) had 2 to 4 mm of eruption. During the
rst posttreatment year (T3-T4), 5 (19%) had an eruption of 2 to 4 mm, but 1 patient had an eruption of 2
to 4 mm. During the second posttreatment year, 4
(16%) had 2 to 4 mm of eruption, and 1 had 2 to
4 mm of intrusion.

TADs to hold the position of the maxillary molars while


orthodontic treatment was completed. The mean change
in maxillary molar position was 0.3 mm of relapse: ie,
extrusion (Table II). The mean change in mandibular
molar position was an extrusion (eruption) of 0.7 mm,
and the mean change in the face height was a 0.2-mm
increase. The maxillary incisors and the mandibular
incisors had mean elongations of 0.7 and 0.8 mm,
respectively. The mean change in overbite was an increase of another 0.9 mm.
The variability in response is shown well in the percentages of patients with changes. Two patients (7%) had 2 to
4 mm of extrusion of the maxillary molars after the splint
was removed (Fig 2), and 5 (17%) experienced 2 to 4 mm
of eruption of the mandibular molars (Fig 3); these
changes accompanied postintrusion increases in anterior
face height of 2 to 4 mm in 5 patients (17%) and greater
than 4 mm in 1 patient (Fig 4). Eight patients had 2 to
4 mm of mandibular incisor elongation, 6 patients had
2 to 4 mm of maxillary incisor elongation, and 1 patient
had greater than 4 mm of maxillary incisor elongation.
Six patients had greater than a 2-mm increase in overbite.
From the end of treatment during 1 year of retention
(T3-T4), the mean changes were a 0.2-mm decrease for
anterior face height and a 0.3-mm decrease for overbite
(Table II). The mean change in maxillary molar position
was a further eruption of 0.5 mm, whereas for the
mandibular molar, it was an intrusion of 0.6 mm.
Some patients had changes large enough to be clinically signicant: 3 patients (11%) had 2 to 4 mm of

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Fig 4. Percent with postintrusion changes in anterior face


height. During T1 to T2, 40% of the patients had 2 to 4 mm
of decrease in face height, and another 10% had greater
than 4 mm. From T2 to T3, 17% of the patients had 2 to
4 mm of increase, and 1 (3%) had greater than a 4-mm increase. In the T3 to T4 period, 2 patients had 2 to 4 mm of
increase, 2 had 2 to 4 mm of decrease, and 12% had increases from T3 to T5. During treatment, the change was
largely reeruption of the intruded molars; after treatment,
vertical growth in the younger patients was a major
contributor to the change.

eruption of the maxillary molars (Fig 2); 5 patients


(19%) showed 2 to 4 mm of extrusion of the mandibular
molars, and 1 patient had intrusion of the mandibular molars of 2 to 4 mm (Fig 3); and 2 patients (7%) showed 2 to
4 mm of increase in anterior face height, whereas 2 had
greater than a 2-mm decrease (Fig 4). None of the patients
had greater than a 2-mm change in the vertical position of
the mandibular incisors or in overbite, but 1 patient had 2
to 4 mm of elongation of the maxillary incisors, and
another had 2 to 4 mm of intrusion of these teeth.
Figure 5 shows the percentages of patients with clinically signicant changes from T1 to T4 for anterior face
height, maxillary and mandibular molars, and overbite.
Anterior face height showed 2 to 4 mm of decrease in
5 patients (19%) and a highly clinically signicant
decrease greater than 4 mm in 3 patients (11%), but 2
patients (7%) also had greater than a 4-mm increase in

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Schefer, Proft, and Phillips

35

599

Percent With Change From Pre-Tx


to One Year Post-Tx (T1-T4)

30
25
20

Percent

15

anterior face height, and none had an increase; 2 patients had 2 to 4 mm of decrease in overbite, and 1 patient had 2 to 4 mm of increase; 4 patients (16%) had 2
to 4 mm of eruption of the maxillary molars; and 4 patients had 2 to 4 mm of intrusion of the mandibular molars, and 1 patient had 2 to 4 mm of eruption.
DISCUSSION

Decrease

Intrusion

Extrusion

Increase

10
5
0
<-4
-4 to -2
2-4
>4

5
10
15
Anterior
Face Height

Maxillary
1 Molar

Mandibular
1 Molar

Overbite

Fig 5. The percentage of patients with clinically signicant (.2 mm) changes from pretreatment to 1 year posttreatment. The percentage with greater than a 2-mm
decrease in anterior face height was greater than the percentage with greater than a 2-mm intrusion of the maxillary rst molar, but much less than twice as great as
would be suggested by the geometry of the mandible.
The number of patients with greater than 2 mm of eruption
of the mandibular rst molar accounts for the discrepancy.
The percent with greater than a 4-mm increase in overbite
is higher than the percent with greater than a 4-mm
decrease in anterior face height; elongation of incisors
is the reason for that.

face height. In evaluating this, it is important to


remember that vertical growth occurred after intrusion
in the younger patients. Maxillary molar intrusions of
2 to 4 mm occurred in 30% of the patients; this was
greater than 4 mm in 11%, and the same percentage
of patients had 2 to 4 mm of mandibular molar eruption.
At the 1-year follow-up, no patient had an open bite,
26% had 2 to 4 mm of increase in overbite, and 33%
had greater than a 4-mm increase in overbite.
For patients who were out of treatment for 2 years or
longer (T3-T5), the mean changes in anterior face
height, overbite, and vertical position of both maxillary
and mandibular rst molars were within a fraction of a
millimeter of the 1-year changes (Table II). The percentages of patients with changes also were similar between
the 1-year (T4) and 2-years-or-longer (T5) groups. At
T5, 3 patients (12%) had 2 to 4 mm of decrease in

The marginal multivariate regression indicated statistically signicant but small differences between younger
and older subjects as well as between male and female
patients in the response to treatment, particularly with
regard to the changes in the position of both the
mandible and the mandibular teeth. The relationship
to age is not surprising because the younger patients
had mandibular growth during and after the intrusion
procedure; the relationship to sex probably occurred
because girls are more mature than boys of the same
age, and their growth declines to adult levels at a
younger age. Because of these differences in the patterns
of change, however, one cannot be precisely sure of the
cause of changes in mandibular position and mandibular
dentition. This must be kept in mind in the interpretation of the mandibular changes.
Positive overbite of at least 1 mm was achieved for all
patients from T1 to T2. The amount of intrusion needed to
obtain a positive overbite varied with the severity of the
initial open bite; this explains the differences in the
amount of posterior intrusion. From jaw geometry,
2 mm of intrusion posteriorly should result in about
4 mm of anterior open-bite closure. In this study, the
mean change in maxillary molar position was 2.3 mm of
intrusion, so one would expect a change in overbite
greater than 4 mm, but the mean change was only 2.2 mm.
There are 2 possible explanations for this. First, eruption of the mandibular posterior teeth while the maxillary teeth are being intruded would decrease the jaw
rotation that would reduce overbite. The data show
that greater than a 2-mm eruption of the mandibular
molars occurred in 3 patients (10%) during intrusion.
One advantage of using the splint is that it tends
to impede eruption of the mandibular teeth, but to
be sure that molar extrusion cannot occur, these
teeth can be ligature-tied or chained to mandibular
miniscrews during maxillary intrusion treatment.14,17
Bilateral mandibular TADs to control or intrude the
mandibular molars are recommended for patients with
severe long face or open bite.
Second, the AOB splint is typically fabricated to cover
the maxillary premolars and molars and not the canines.
Thus, the intrusion force is applied to all posterior teeth,
whereas the canines and the incisors are not affected. In

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600

some patients, when the splint is removed, the canines


are the only teeth that contact, a posterior open bite is
present, and the potential increase in overbite is not fully
expressed because of the premature contact of the
canines (Fig 6). Our experience suggests that some intrusion of the maxillary canines often is needed, and when
this is the case, it would improve mandibular rotation to
include them in the fabrication of the AOB splint or have
an archwire from rst premolar to rst premolar so that
the canines are intruded slightly along with the intrusion
of the rst premolars (Fig 1, B).
Clinical observation suggests that the rate of intrusion decreases with time, but no good data are available
to document this. It is difcult to justify multiple cephalograms during intrusion and difcult to measure the
rate of intrusion directly with adequate accuracy. One
possibility is that as a tooth is intruded, cortical rather
than medullary bone is likely to be encountered, especially in patients in whom the downward movement of
the maxillary teeth during growth was due primarily to
growth of the maxilla, not to supereruption of the teeth.
Although the maximum amount of intrusion that can
be obtained is unknown, the greatest intrusion in this
sample was 6.7 mm during 10 months of intrusive force
with the splint. However, in this same nongrowing adult
patient, the mandibular molars extruded 6.2 mm, and
the anterior face height decreased by only 1.3 mm.
During T2 to T3, when the splint is removed, eruption
of the maxillary posterior teeth is inhibited by tying the
archwire to the TAD, but the mandibular molars are free
to erupt, especially if canine interference creates a temporary posterior open bite.
During this time period, the maxillary rst molars
were relatively stable, but 2 patients had 2 to 4 mm of
eruption (Fig 2). For the mandibular rst molars, the
mean change was 0.7 mm of eruption, and almost
20% of the patients had greater than 2 mm of eruption
(Fig 3). Both the maxillary and mandibular incisors also
showed eruption during the postintrusion orthodontics,
with mean changes for the maxillary incisor of 0.7 mm, 2
to 4 mm of eruption in 6 patients (22%), and greater
than 4 mm in 1 patient. This is not necessarily undesirable; elongating the maxillary incisors to obtain optimal
display of the incisors is a necessary part of treatment for
some patients. For the mandibular incisors, 2 patients
had increases of 2 to 4 mm and 1 patient had greater
than a 4-mm increase. Eruption of the incisors was a factor in maintaining a positive overbite and the main
reason that the mean change in overbite during xed
appliance treatment was an increase of 0.8 mm.
Sugawara et al14 reported a 30% relapse of the
mandibular molars at 1 year posttreatment, and Baek
et al15 reported a 23% relapse of the maxillary molars

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Fig 6. When the posterior occlusal covering splint is


removed after intrusion, the canines are frequently the
only teeth that contact; this causes a posterior open bite
and a less positive overbite than what otherwise would
have been expressed after molar intrusion treatment.

over a 3-year retention period, with 80% of the relapse


occurring during the rst year. Since these ndings
were previously known, many patients in our study
were left with a mild posterior open bite after intrusion
and after treatment to allow for some relapse of the
maxillary molars. The percentage with clinically signicant relapse of the maxillary molars was relatively small:
11% of our patients showed greater than 2 mm of eruption after 1 year and 16% at 2 years. This also was the
case for relapse in overbite: 15% and 22% of the patients
showed relapses in overbite greater than 1 mm after
1 year and 22% at 2 years, but none had greater than
a 2-mm change (Table II).
During retention, an anterior open-bite retainer with
occlusal coverage was given to the patients. It is interesting that the mandibular molars that erupted during
active orthodontics often intruded after the appliance
was removed. It is possible that this was related to biting
pressure on the occlusal coverage retainer.
Sugawara et al14 and Baek et al15 reported extrusions
of incisors during retention to help maintain or deepen
the bite that counteracted the bite opening caused by
molar eruption. In our study, 4% and 8% of our patients
showed intrusions, not extrusion, of the maxillary incisors greater than 2 mm after 1 year and 2 years, respectively. It is likely that the incisors that were elongated
during treatment relapsed during retention.
There were some clinical implications in the comparisons with orthognathic surgery outcomes. Selected outcomes in 37 patients who had a LeFort I osteotomy at
the University of North Carolina during the same time
period as the intrusion patients are compared in
Figure 7. The patients selected for surgery had signicantly larger open bites before treatment. Correction
of the open bite created an average of 1 mm of overbite
in both the surgery and intrusion patients. There was

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601

some posttreatment decrease in overbite in both groups,


but less than would have been expected from the
amount of downward movement of the molars because
of compensatory elongation of the maxillary and
mandibular incisors: ie, elongation of the incisors
occurred in the surgery and intrusion patients as a way
to maintain overbite. The ndings from this surgery
sample are consistent with previous reports on postsurgical stability.19-21
As one would expect, the surgery patients had no
change in the relationship between the maxillary rst
molar and the palatal plane, whereas the intrusion
patients had a signicant decrease (Fig 7). In contrast,
the intrusion patients showed no change in the inclination of the palatal plane to SN, but the surgery patients
had an increase in this angle as the posterior maxilla was
elevated. The mandibular plane angle had little change
in the intrusion patients and an average decrease of
2.5 for the surgery patients. In the rst posttreatment
year, there was a slightly greater downward movement
of the maxillary molars in the surgery group than in
the intrusion patients. It seems reasonable that in the
surgery group this was largely due to the slight downward repositioning of the maxilla and to the reeruption
of the teeth in the intrusion group. Beyond 1 year postsurgery, downward movement of the maxilla, much like
a resumption of the original pattern of growth, was
observed in about 20% of the patients.21
In this study, the maxillary rst molars were intruded
by 2.3 mm during active intrusion; this was the same as
Deguchi et al16 reported in a study of 15 patients and
similar to the 2.4 mm that Baek et al15 reported for 9 patients. Kuroda et al13 reported an average 3.3 decrease
of the MPA for the group treated with surgery and no
change in the group treated with TADs. Akan et al,22
in a more recent report of 19 patients in whom intrusion
force was delivered to an occlusal splint, reported a mean
intrusion of 3.4 mm and a 3.8 decrease in the MPA, but
they presented no data beyond the period of active
intrusion.

=
decrease, but this distance should not change because
Fig 7. Comparison of changes from pretreatment to
1 year posttreatment in the patients with molar intrusion
with a sample of patients treated with LeFort I osteotomy
to superiorly reposition the mandible: A, the average
severity of the open bite before surgery was greater
than for the intrusion patients, but the correction to positive overbite was almost exactly the same for the 2
groups, and the amount of posttreatment change also
was similar; B, during intrusion, one would expect the distance from the maxillary molar to the palatal plane to

of a maxillary osteotomy; this is what occurred. This distance was similar for the surgery and intrusion patients:
ie, both groups experienced downward eruption of the
molars to about the same extent. C, Change ( ) in the
orientation of the palatal plane to the S-N line; this would
not be expected to change in the intrusion patients and
did not; it did change in the surgery patients since the
maxilla was usually rotated at surgery. The intrusion
patients had a zero orientation, much closer to normal
than the surgery patients.

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CONCLUSIONS

1. Intrusion of maxillary posterior teeth can give


satisfactory correction of moderately severe anterior
open bite, with elimination of 5 to 6 mm of open bite,
but some of the change in the position of the mandible
is likely to be lost after treatment as the intruded teeth
reerupt by 0.5 to 1.5 mm.
2. Controlling the vertical position of the mandibular
molars, so that they do not erupt as the maxillary teeth
are being intruded, is important in obtaining a decrease
in face height.
3. Part of the open-bite correction in most patients
with molar intrusion is slight incisor elongation, which is
rarely as much as 2 mm and never more than that. This occurs primarily during the nishing phase of treatment.
4. In comparison with maxillary molar intrusion as
accomplished in this study, LeFort I surgery is more likely
to produce shortening of anterior face height.
ACKNOWLEDGMENTS

8.

9.

10.
11.

12.
13.

14.

15.

We thank Debora Price for digitizing the cephalograms and developing the intrusion and surgery data bases, Sean Chen for the logistic regression calculations,
Luke Current and Amanda Pritchard for their assistance
in compiling the cephalograms for analysis, and Gibson
McCall, Turner Hull, and Camilla Tulloch for their pilot
investigations.

16.

17.

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